Manual therapy and migraine treatment

Chronic migraines are not well understood in the literature but are a severe issue for healthcare providers, as well as a socioeconomic burden for those who suffer with headaches.

Chronic headache is defined as having more than 15 headache days a month, over more than a 3-month period. It is hypothesised that neurological changes in the trigeminocervical caudalis nucleus of the brain can cause an increase in sensitivity threshold, in which an individual who suffers from chronic headaches becomes more likely to have reoccurring pain and headaches.

A common treatment to address this sensitivity are injections of OnabotulinumtoxinA (commercially known as Botox) for management of the pain and musculature around the head and neck. In addition to pharmacological interventions, physiotherapy and pain management strategies such as TENS are often used as adjunctive therapies.

This study aimed to determine if manual therapy would offer greater benefit than TENS as an adjunctive therapy for pain management and quality of life improvement.

Two groups received treatment for 4 weeks; one session weekly, each session lasting 30 minutes.

The manual therapy group received input in the form of 5 minutes of relaxation therapy, and then manipulative techniques consisting of myofascial release and mobilisations targeted at the occipital-atlas joint and thoracic spine. Sessions were concluded with another 5 minutes of relaxation therapy.

The TENS group started each session with 5 minutes of relaxation, received 20 minutes of portable TENS machine input at a biphasic rate, and frequency at 150Hz. Intensity was increased up to the patient’s tolerance. The electrodes were placed on the upper traps at the acromial tendon.

All patients were asked to keep a daily log. Through analysis of this diary, outcomes were defined as any changes in:

Number of days without headache per month and total time with headache (hrs) per month;

Headache intensity reported as total hours of mild, moderate or severe headache per month;

Total consumption of analgesics, NSAIDs and triptans per month.

Quality of life and disability were assessed according to the Headache Impact Test-6 (HIT-6) and the Migraine Disability Assessment Scale (MIDAS).

It was found that the group receiving manual therapy intervention had an improvement in overall pain management. The TENS group was found to have some relief, but not as clinically significant as the manual therapy group.

Two possible reasons for this improvement were speculated on: one being that trigger point release and joint manipulation have shown to help alleviate muscle spasms and nociceptive system by improving vascular circulation. The other reason is that manual therapy might possibly reduce the threshold for dorsal horn neurons for pain innervation.

One of the strengths of this article is that both groups were receiving the same medical intervention, and that testing groups were only distinguished by adjunctive treatment. This article supports the notion that combining a pharmacological and non-pharmacological approach can be beneficial in migraine management.

Expert opinion by Jessica Povall

Additionally in this study, it would have been interesting to record the patients’ perception of why manual therapy was of benefit, and possible placebo effects of manual therapy (both targeted and generalised) in this intervention group.

Existing literature shows a perceived benefit of hands-on therapy in those who suffer from persistent pain as opposed to just an exercise or education approach to treatment (inspite of the general consensus that education and exercises have the greatest impact on pain).

Noteworthy, both groups in this study received some form of relaxation therapy, and the positive impact of relaxation therapy in pain management is well documented.

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